When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
National Cancer Institute. NCI Dictionary of Cancer Terms. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/locally-advanced-cancer. Accessed on February 21, 2020.
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Bladder Cancer, version 3.2020. Revised January 17, 2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf. Accessed on February 21, 2020.
Oken M, Creech R, Tormey D, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649-655.
Richards KA, Jarrard DF. Urothelial Tumors of the Renal Pelvis and Ureters. Jan 15, 2020. Medscape. Available at: http://emedicine.medscape.com/article/452449-overview#a8. Accessed on February 21, 2020.
Rosenberg JE, O’Donnell PH, Balar AV, et al. Pivotal trial of enfortumab vedotin in urothelial carcinoma after platinum and anti-programmed death 1/programmed death ligand 1 therapy. J Clin Oncol. 2019;37(29):2592-600.
US Food and Drug Administration. Center for Drug Evaluation and Research. PADCEV™ (enfortumab vedotin-ejfv). Approval Letter. [FDA Web site] Available at: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2019/761137Orig1s000Approv.pdf. Accessed on February 18, 2020.
US Food and Drug Administration. Center for Drug Evaluation and Research. PADCEV™ (enfortumab vedotin-ejfv). Product Labeling. [FDA Web site]. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2019/761137Orig1s000Lbl.pdf
Accessed on February 18, 2020.
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C65.9 Malignant neoplasm of unspecified renal pelvis
C66.1 Malignant neoplasm of right ureter
C66.2 Malignant neoplasm of left ureter
C66.9 Malignant neoplasm of unspecified ureter
C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.8 Malignant neoplasm of overlapping sites of bladder
C67.9 Malignant neoplasm of bladder, unspecified
C68.0 Malignant neoplasm of urethra
C68.8 Malignant neoplasm of overlapping sites of urinary organs
C68.9 Malignant neoplasm of urinary organ, unspecified
This policy has been identified for a HCPCS code update, effective 07/01/2020.
The following HCPCS code has been added to this policy: J9177.
The following HCPCS codes has been deleted from the policy: C9399 & J3590.